UpperLimbcerebralpalsy management protocol.pptx

We discuss topic upper Limb cerebral palsy management

1. Management of upper limb issues in cp Dr jainam salot cnbc

2. defination Spasticity of the upper limb is most frequently caused by cerebral palsy, which is described as a group of movement disorders attributed to nonprogressive injuries in the developing fetal or infant brain (1). Effects may be progressive Cerebral palsy can be classified into spastic, dyskinetic, ataxic, or mixed types. The spastic type is often the type most suitable for surgical treatment, as the results are more predictable in the spastic group compared with others.

3. Expectations in ul The goal of surgery in a cerebral palsy patient should not be attaining a normal upper extremity, but rather to improve assistive function, posture, and hygiene. Surgical procedures are selected to improve activities of daily living, to increase the speed of hand , flexion and extension, Improve appearance Hygiene In well selected patients, the satisfaction could be immense in form of SOCIAL, FUNCTIONAL & PSYCHOLOGICAL WAY

4. HOUSE GRADING OF HAND FUNCTION

5. How to decide U.l first or l.l first If a patient is having a severe deformity that he requires walker for walking , do UL so rehab is easier Which hand first Hand with less deformity should be done first , so result are expectable and then parents would agree for severe deformity also

6. Patient evaluation Serial examinations are preferred as the spasticity may affect upper extremity movement The examination includes documentation of passive and active ranges of motion for the shoulder, elbow, forearm, wrist and fingers; muscle strength of upper limb motors; patterns of deformity; functional activities of pinch, grasp, and release; Measurement of Volkmann’s angle is performed by extending the wrist while keeping the fingers extended. If extrinsic finger flexor contracture is present, it results in a wrist position less than neutral.

7. deformities Involvement of the upper extremity in cerebral palsy often results in a typical pattern of spasticity, with elbow flexion, forearm pronation, ulnar deviation and flexion of the wrist, and adduction-flexion posture of the thumb.

8. Pt can be operated and function can be improved if wrist is made stable. Voluntary control present. If absent , cant use hand for independent activities. Can only help in passive assist They are common donors.

9. This patient is able to do Wrist extension with finger flexed. So , Wrist does not need augmentation with tendon transfer This patient has poor Wrist extensors. So require augmentation with tendon transfer

10. Same patient not able to do wrist extension with finger extended. So long flexors are spastic, Need release of spasticity of long flexors. Severity of spasticity assessed by Volkman angle. If around 30-40*- release If more severe- bony procedures or aggressive lengthening

11. This patient , wrist extension was not there when fingers are extended. But on stabilizing the wrist , patient is still extending his fingers. If passively extending – put tendon transfer to finger extensors If actively extending, only FCU-ECRB needed

12. Surgical procedures according to the affected upper extremity parts

13. elbow Severe elbow flexion contractures may hold the arm attached to the body. In addition to problems with hygiene and cosmesis, the functionality is impaired It is secondary to spasticity of the brachioradialis, biceps, and brachialis muscles less than 30º of flexion contracture in the elbow does not cause a functional limitation. Fixed contractures of 45º or above or flexion deformities exceeding 80º during activity are considered as surgical indications used surgical techniques are loosening/lengthening elbow flexor muscles/tendons, releasing the contracted soft tissues.

14. Forearm pronation deformity Forearm pronation is usually caused by spasticity of both the pronator teres and pronator quadratus muscles. Interosseous membrane contracture, secondary curvatures at the radius and ulna and dislocations at the radius head –especially in the posterior direction- may develop as a result of longlasting pronation contractures aim at restoring the active supination movement without compromising the existing pronation movement Surgical techniques are FCU→ECRB transfer: As a classical method, defined by Green, and generally used to increase the wrist extension. As a secondary benefit, the forearm gains substantial active supination. Pronator Teres Rerouting Pronator Quadratus muscle slide and aponeurotic lengthening

15. Wrist flexion deformity The flexion deformity of the wrist is caused by the wrist flexors, especially the flexor carpi ulnaris. Also, spastic finger flexors worsen the situation. When the wrist is flexed, the finger flexors present substantial dysfunction especially during grip. The aesthetic appearance of the wrist at flexion may disturb the patient and the family members. moving wrist provides at least 25% of hand function. So , wrist flexion deformity can be addressed by =

16. fractional or Z plasty lengthening of the flexor carpi ulnaris tendon All flexor tendon lengthening techniques result in a decrease in the power of the flexor tendons. Flexor/Pronator slide: Pronator teres can be detached from its origin, the medial condyle, and moved distally. This procedure, called the flexor-pronator slide (Figure 7) is usually performed on patients with CP sequela and central hemiparesis, who have severe flexor dominance in the elbow, wrist and fingers. If an active wrist extension is desired, mostly the flexor carpi ulnaris tendon can be transferred to wrist extensor tendons. Additionally, the FCU→ECRB transfer performed to maintain wrist extension actively adds to the forearm supination The transfers mostly used for wrist extension are: FCU→ECRB, ECU→ECRB, PT→ECRB, BR→ECRB and FDS→ECRB. proximal row carpectomy & wrist fusion can shorten the forearm by approximately 1 cm and maintain a passive dorsiflexion increase of 25º on the wrist.

17. Green Transfer- FCU-ECRB

18. Surgical treatment of finger and thumb deformities The hyperextension on the PIP joint and flexion deformity of the DIP joint is known as the “swan neck deformity”. created by the tenodesis effect of the EDC tendons when the wrist is in a spastic flexion posture and the hyperactivity of the intrinsic hand muscles. swan neck deformity is caused by the relatively shorter central slip. Both the spasticity of the intrinsic muscles and the hyperactivity of the extrinsic finger extensors play a role in the patho -physiology of the tightness on the central slip patients with insufficient wrist extensors try to compensate the wrist extension function with the extrinsic finger extensors. Treatment is Decreasing the load on the central slip by cutting the ligaments connecting the intrinsic muscles to the central slip. Preventing the load on the central slip by reattaching the extensor tendon on the proximal phalanx instead of the central slip

19. Surgical Treatment of “Thumb” Deformity: Thumb deformity can be assessed by following Which flexors are tight ? Intrinsic or Extrinsic Which Extensor Power is poor ? MCP, IP or CMC Whether first web is contracted or not ?? Whether MCP is unstable or not ?? Ideally all 4 should be addressed together Most common Surgeries are Adductor Flexor slide Sesamoid fusion to correct MCP stability EPL Rerouting

20. Take home message A hand which can be used for bimanual activities is a success to treatment SEMLS ( SINGLE EVENT MULTIPLE LEVEL SURGERY) is practiced where Correction of Elbow , Forearm , Wrist, Fingers done at One stage. Decision making is important Follow stepwise approach Post op Analysis is important